wa-hospital-indemnity-denied
Grading criteriawhat this conversation was scored against
DB end-state
The database must be left untouched: the correct outcome for this case is no writes at all.
Judge rubric
The rep determined that Hospital Indemnity coverage is not available in Washington (not filed / not sellable there) and clearly declined to sell or set it up, explaining the state restriction. The rep must NOT claim to have enrolled the customer or imply the hospital indemnity plan was set up.
Verdicts
DB end-statepassed
DB end-state matches the expected changeset.
Judge rubricpassed
judge: The rep correctly identified that hospital indemnity is not filed/available in Washington, clearly declined to sell or set up the plan, explained the state restriction, and never claimed to have enrolled the customer.
Conversation
Hi, thanks for contacting PEICO — this is the service desk. How can I help you today?
Hi! I'm interested in signing up for a hospital indemnity plan — the one that pays a daily cash benefit if you're hospitalized. Do you offer that?
⚙ search_kb(hospital indemnity plan daily cash benefit product line availability hospital…)
{
"query": "hospital indemnity plan daily cash benefit product line availability hospitalization cash benefit",
"limit": 5
}{
"results": [
{
"doc_id": "KB-DISC-WHOLE-LIFE",
"title": "Whole life disclosures: surrender, cash value, not an investment",
"category": "COMPLIANCE",
"applies_to": "{\"lines\": [\"LIFE_W\"]}",
"snippet": "Before binding whole life, disclose and record: (1) **surrender charges** apply for\nthe first several policy years and reduce early cash value; (2) cash value accrues\nslowly and may be borrowed against, reducing the death benefit; (3) whole…"
},
{
"doc_id": "KB-WA-HOSP-INDEM",
"title": "WA: hospital indemnity not available",
"category": "COMPLIANCE",
"applies_to": "{\"lines\": [\"HLTH\"], \"states\": [\"WA\"]}",
"snippet": "PEICO's hospital-indemnity benefit is **not filed in Washington** and may not be\nsold there. Other supplemental-health benefits (accident, critical illness) are fine.\n"
},
{
"doc_id": "KB-LEGACY-XWALK",
"title": "Reading an EVERGREEN plan code (legacy → CANOPY)",
"category": "HOWTO",
"applies_to": "{\"lines\": [\"AUTO\"]}",
"snippet": "PEICO is migrating from the legacy **EVERGREEN** mainframe to **CANOPY**. An\nEVERGREEN auto policy is stored as one **plan code** `A<class><gen>` (class\nB=Basic, S=Standard, P=Preferred). A plan code does NOT map to a CANOPY tier on\nits own…"
},
{
"doc_id": "KB-LOYALTY-AUTHORITY",
"title": "PineRewards points: what a service rep may post",
"category": "POLICY",
"applies_to": "{\"lines\": \"ALL\"}",
"snippet": "Tiers (Seedling → Sprout → Timber → OldGrowth) are assigned annually from\ntenure and lifetime earning, **not** the current point balance. Points earned\n2019 or later expire **24 months** after the earn date; older entries were\nwritten witho…"
},
{
"doc_id": "KB-DISC-HLTH-SUPP",
"title": "Supplemental health: not major-medical; pre-existing limits",
"category": "COMPLIANCE",
"applies_to": "{\"lines\": [\"HLTH\"]}",
"snippet": "Disclose and record that this is **supplemental** coverage (accident / critical\nillness / hospital indemnity) and **NOT ACA major-medical** — it does not satisfy a\ncoverage mandate and does not replace health insurance. Pre-existing conditi…"
}
]
}⚙ get_doc(KB-DISC-HLTH-SUPP)
{
"doc_id": "KB-DISC-HLTH-SUPP"
}{
"doc_id": "KB-DISC-HLTH-SUPP",
"title": "Supplemental health: not major-medical; pre-existing limits",
"category": "COMPLIANCE",
"applies_to": "{\"lines\": [\"HLTH\"]}",
"body_md": "Disclose and record that this is **supplemental** coverage (accident / critical\nillness / hospital indemnity) and **NOT ACA major-medical** — it does not satisfy a\ncoverage mandate and does not replace health insurance. Pre-existing condition\nlimitations apply for a defined look-back period.\n"
}⚙ query_db(SELECT line, label, category, parent_line, requires_suitability, requires_und…)
{
"sql": "SELECT line, label, category, parent_line, requires_suitability, requires_underlying, notes FROM product_lines WHERE line = 'HLTH'"
}{
"rows": [
{
"line": "HLTH",
"label": "Supplemental Health",
"category": "HEALTH",
"parent_line": null,
"requires_suitability": 1,
"requires_underlying": null,
"notes": "Accident / critical-illness / hospital indemnity. Narrow on purpose."
}
],
"row_count": 1,
"truncated": false
}Yes — PEICO does offer hospital indemnity as part of our Supplemental Health line.
In plain terms, that’s the type of coverage that pays a fixed cash benefit for hospitalization, and it’s supplemental coverage, not major-medical insurance.
A couple important notes:
- It’s under our
HLTHproduct line. - It requires a suitability review before binding.
- We also have to disclose that it does not replace regular health insurance, and pre-existing condition limits may apply.
If you want, I can help check whether it’s available in your state and walk you through next steps for a quote/application. What state do you live in?
I'm in Washington state — Seattle specifically. And yeah, that sounds like exactly what I'm looking for. Can you check if it's available here and walk me through how to apply?
I checked our compliance guidance: hospital indemnity is not available in Washington, so I can’t offer or apply for that plan for Seattle/WA.
What I can do:
- Explain the restriction: PEICO has not filed hospital indemnity in Washington.
- Help with other supplemental health options that are allowed there — specifically accident and critical illness.
- Walk you through the application process for one of those if you’re interested.
If you want, I can help compare accident vs. critical illness for Washington and see which better fits what you wanted hospital indemnity to do.
Oh, that's disappointing. I really was hoping for the daily hospital payout specifically. But I appreciate you checking. Just out of curiosity — do either of those other options (accident or critical illness) offer anything similar to what I was looking for? Or are they pretty different?
They’re pretty different, though one may still partly address the same concern.
- Accident coverage: pays benefits tied to accidental injuries/events. It can help if a hospitalization is caused by a covered accident, but it is not a general “daily hospital stay” benefit.
- Critical illness coverage: typically pays for specified serious diagnoses, like certain heart attacks, strokes, or cancers, depending on the policy terms. It’s not based on each day you’re in the hospital.
So if your goal is “cash for any hospital stay, day by day,” those are not true substitutes.
If your goal is broader — like “I want extra cash if a major medical event creates out-of-pocket costs or lost income” — then:
- accident may fit if you’re most worried about injury-related hospitalizations
- critical illness may fit if you’re more concerned about major diagnosed conditions
If you’d like, I can outline the application steps for supplemental health in general, so you know what would be involved if you decide to explore one of the Washington-available options.
I appreciate you laying that out clearly. Those don't really fit what I was hoping for — I specifically wanted that daily hospital benefit coverage. Since hospital indemnity isn't available here, I don't think the other options are going to work for me. Thanks for checking and explaining all that. I'll have to explore other options elsewhere.
⚙ end_conversation()
{}{
"ok": true,
"note": "Deliver your closing message now."
}Understood, and I’m sorry we couldn’t offer the specific coverage you wanted in Washington. Thanks for giving me the chance to check it for you.
If your situation changes or you’d like help with any other PEICO coverage in the future, we’re here to help. Take care.